Monroe, Fred �oq+N of QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �'�1.
/�
Name �/l�"`t i /) ;c_/�l�/'j�� Case #
Date of Cremation
1 �`7
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks :
PA"
TOWN OF OUEENSHURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name) (Sex)
of ! 1^Ot,� 13 i�oa
(Street )) (City) (State)-' (Zip Code)
who died on �day of F�10 - 19
at [eN5in��S QS/21' (n ��a:s Flo
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
�'IA r�'oti IrnUN ra ,2 V Tani
(Name) (Address)
Relationship to the deceased w� �e—
Name of Funeral Home ?" //� / VA.Jer�°� -NOw-(-'—
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct
possessionsshavete�ther
n of
the cremated remains, that any personal
been removed or may be destroyed, and agree to protect, defend
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
J61A'5-30Tsh6W0v-JRd� w�st-
(Witness) (Address) p j
(Signature of Relative or Legal Rep. and Address)
Signed on this date: ����
I
FIA5 / / C- T'4 I"'o � �
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows : I
Mail to ttJ.IY� �D'
Other arrangements - please specify:
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
1 . The crematorium will be open for cremations 5 days a week 7 : 00
A.M. - 3 : 30 P.M. Monday-Friday. No Holidays or Sundays,
arrangements can be made for Saturday. Prearrangements by
telephone for acceptance of remains is necessary. *
2 . Pine View Crematorium is located on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
3 . An authorization for cremation properly signed by the nearest
next of kin or other authorized person stating that they do have
the power and authority to arrange for the cremation of the remains
and to direct the disposition of the cremated remains, that any
personal possessions have either been removed or may be destroyed
and agree to protect, defend and save harmless Pine View
Crematorium from any and all claims and demands for loss of damages
which may be made against them by reason of or connected with the
cremation of said remains and/or disposition of said remains as
directed, whether such claims or demands are, or are not wholly
groundless, false or fraudulent. This authorization in addition to
a regular burial permit must accompany the remains .
4 . All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible material.
No styrafoam or plastic containers will be accepted.
5 . The question relative to cardiac pacemakers must be answered on
the authorization to cremate form before the remains will be
accepted.
6 . Unless other arrangements are made the cremated remains will be
mailed via Registered U.S. Mail within three days of cremation to
the funeral home handling the service. There will be a $20.00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $195 . 00 —
Children (age 13 months to 12 years ) $115 . 00 Infants (stillborn to
12 months ) $75 . 00
* Additional $50 . 00 charge for cremations done after 3 :00 P.M.
Monday through Friday. Cremations done on Saturdays will be
charged the additional $50 . 00.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Fred H. Monroe Male
Date of Death Age If Veteran of U.S. Armed Forces,
Feb. 2, 1999 70 War or Dates no
Place of Death City of Glens Falls Hospital, Institution or Glens FAlls Hospital
City, Town or Village Street Address
;. Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
John Ruggi MD
Address
Warrensburgh, New York
Death Certificate Filed District Number Register Number
City, Town or Village City of Glens Falls 5601 5
Date Cemetery or Crematory
❑Burial Feb. 4, 1999 PineView Crematory
Address � ry
Cremation .Tn of eensbue New York
Date Place Removed
o❑Removal and/or Held
.•• and/or Address
Hold
Q Date Point of
0.
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Honlzaard L. Kelly Funeral Home 01045
Address
Schroon Lake, New York 12870
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains descri/b d abo e a ndi d
Date Issued2—+-99 Registrar of Vital Statistics
5601 City of (6'Vg 'rValls, New York
District Number Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
g Date of Disposition Place of Disposition I�W C- ,6 /g' ®JP(V
(address)
Uj
tM (section) (lot number) (grave number)
GName of Sexto or Person in Charge of Premises
z (please print)
Signature Title U1-7-
(over)
DOH-1555 (9/98)
DOH-1555 (10/89) p. 1 of 2 VS-61
(over)
DOH-1555 (9/98)